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Medicine > Cardiology > Flashcards

Cardiology Flashcards

1
Q

Angina pectoris 3 features

A

Constricting chest pain
Brought on by exercise
Relieved within 5 min by rest or GTN

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2
Q

Angina symptoms

A

Constricting chest pain, sweatiness, nausea, dyspnoea, faintness

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3
Q

Investigations for angina

A

ECG - normal, or ST depression, T wave inversion, signs of past MI
Bloods - FBC, U+E, TFT, lipids, HbA1c, cardiac enzymes to rule out MI

In patient’s whom stable angina cannot be excluded, first line test is CT coronary angiography

Consider echo and CXR
Exercise ECG, stress echo

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4
Q

Stable angina management

A

Secondary prevention - stop smoking, dietary advice, hypertension control, diabetes control, 75mg aspirin, statins, consider ACEi

Symptom relief - GTN spray

Anti-angina - beta blocker and/or CCB 
Consider revascularisation (PCI, CABG)
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5
Q

Risk factors for acute coronary syndrome

A

Non-modifiable: Age, sex, family history

Modifiable: Smoking, obesity, HTN, DM, hyperlipidaemia, sedentary lifestyle

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6
Q

ACS investigations

A 
Troponin/cardiac enzymes (normal in UA, raised in NSTEMI/STEMI)
ECG
Other bloods - FBC, U+E, glucose, lipids
Echo
CXR
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7
Q

ECG in ACS

A

STEMI - ST elevation, hyperacute T waves, new LBBB (T waver inversion and pathological Q waves come hours/days later)

UA/NSTEMI - Normal, T wave inversion, ST depression, non-specific changes

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8
Q

Acute management of STEMI

A

Morphine, metoclopramide, oxygen, GTN, aspirin 300mg

Consider adding clopidogrel
Fondaparinux
Beta blocker

If <12hr from symptoms and <120 min from first medical contact -> PCI
If >120 min -> fibrinolysis

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9
Q

Acute management of NSTEMI

A

Morphine, metoclopramide, nitrates, aspirin (300mg), oxygen

Calculate GRACE score
Low risk -> secondary prevention, discharge, follow up
High risk -> fondaparinux, add clopidogrel, beta blocker, IV nitrate is pain continues, +/- abciximab, cardiology review for angiography

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10
Q

Secondary prevention following ACS

A 
Stop smoking
Control DM and HTN
Statins
Diet and exercise
75mg aspirin OD and ticagrelor for at least 12m
Fondaparinux until discharge
Beta blocker
ACE inhibitor
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11
Q

Driving after MI

A

1 week after successful angioplasty, 4 weeks after ACS without angioplasty

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12
Q

Working after MI

A

Depends on the patient and the nature of their work. Can not continue being an airline pilot or air traffic controller.
May need to wait if job involves driving

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13
Q

Complications of MI

A

Cardiac arrest, cardiogenic shock, heart failure, arrhythmias, pericarditis, embolism, cardiac tamponage, mitral regurg, VSD, dresslers syndrome

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14
Q

Causes of arrhythmias

A

IHD, structural changes, cardiomyopathy, pericarditis

Caffeine, smoking, alcohol, pneumonia, drugs, metabolic imbalance, pheochromocytoma

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15
Q

Investigations for arrhythmias

A 
FBC, U+E, glucose, calcium, magnesium, TSH
ECG
24h ECG or continuous ECG monitoring
Echo
Exercise ECG/cardiac catheterisation
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16
Q

Types of regular narrow complex tachycardias

A 
Sinus tachycardia (infection, pain, anxiety, exercise, alcohol, caffeine, etc)
Atrial flutter (atrial activity 300bpm with regular ventricular activity -> sawtooth appearance)
Atrioventricular re-entry tachycardia (eg. WPW, accessory path from atria to ventricles)
Atrioventricular nodal re-entry tachycardia (circuit formed around the AVN, very common)
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17
Q

Types of irregular narrow complex tachycardias

A

AF

Atrial flutter with a variable block (atrial rhythm is regular but ventricular rhythm is irregular)

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18
Q

Management of supraventricular (narrow complex) tachycardias

A

If there are adverse signs (shock, syncope, MI, HF) -> synchronised DC cardioversion, and/or amiodarone (300mg over 20min then 900mg over 24h)

No adverse signs ->
irregular -> treat as AF (beta blocker/CCB/digoxin, consider amiodarone or cardioversion, give anticoag)

No adverse signs ->
regular -> vagal manoeuvres, adenosine (6,12,12) -> if sinus not achieved seek expert help, if sinus achieved then monitor

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19
Q

Types of broad complex tachycardia

A

VF
VT
Torsades de pointes (polymorphic VT)
Any cause of narrow-complex tachycardia when in combination with a BBB

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20
Q

Management of broad complex tachycardia

A

Adverse signs -> synchronised DC cardioversion, +/- amiodarone

No adverse signs -> correct electrolyte problems
If regular give amiodarone
If irregular seek expert help
If no success give syncronised DC cardioversion

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21
Q

AF causes

A

HF, HTN, IHD, PE, mitral valve disease, pneumonia, hyperthyroidism, caffeine, alcohol, post-op, hypokalaemia, hypomagnesaemia

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22
Q

Investigations for AF

A

ECG (irregularly irregular, absent P waves)
U+E, TFT, cardiac enzymes
Echo (look for left atrial enlargement, mitral valve disease, poor LV function, structural abnormalities)

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23
Q

Managing acute AF

A

Adverse signs -> synchronised DC cardioversion +/- amiodarone

No adverse signs and AF started <48hrs ago -> rate control (BB, CCB, digoxin) or rhythm control (cardioversion, flecainide, or amiodarone)

No adverse signs and started >48hrs ago -> rate control. If rhythm control indicated then pt must be anticoagulated for >3weeks

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24
Q

Contraindication for flecainide

A

Structural heart disease, IHD

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25
Q

Managing chronic AF

A

Rate control or rhythm control

Rhythm control indications: symptomatic or HF, younger, AF due to a corrected precipitant. Rhythm control can be DC cardioversion or flecainide (if IHD/structural heart disease use amiodarone)

Rate control includes beta blocker (bisoprolol), or CCB (diltiazem). Add in digoxin if unsuccessful. Use digoxin monotherapy if other two are contraindicated or if HF.

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26
Q

Anticoagulation and AF

A 
CHA2DS2Vasc
0 - no anticoag
1 (male) - offer anticoag
1 (female) - no anticoag
2 - give anticoag

Give DOAC or warfarin (INR 2-3)

HASBLED gives you a score for risk of bleeding whilst on anticoag

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27
Q

Wolf Parkinson White

  • what is it
  • what does ECG show
A

Congenital accessory pathway between atria and ventricles
Resting ECG shows short PR interval, wide QRS complex (slurred upstroke or delta wave), and ST-T changes
Management may include ablation of the pathway

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28
Q

Causes of sinus bradycardia

A

Physical fitness, vasovagal attack, drugs (BB, digoxin, amiodarone), hypothyroidism, hypothermia, raised ICP, cholestasis

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29
Q

Types of heart block

A

1st degree: long PR interval

2nd degree Mobitz 1: progressive lengthening of PR then a dropped QRS then pattern resets (Wenckebach phenomenon)

2nd degree Mobitz 2: QRS regularly missed (2:1 or 3:1, etc). May progress to complete heart block.

3rd degree/complete heart block: no relationship between P wave and QRS. Haemodynamic compromise. Emergency. PPM required.

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30
Q

Causes of complete heart block

A

IHD, idiopathic, congenital, aortic valve calcification, cardiac surgery, trauma, digoxin toxicity

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31
Q

Hypercalcaemia on ECG

A

short QT

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32
Q

Hypocalcaemia on ECG

A

long QT, small T waves

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33
Q

Hypokalaemia on ECG

A

Small T waves, prominent U waves, peaked P waves

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34
Q

Hyperkalaemia on ECG

A

Tall tented T waves, small/absent P waves, broad QRS, sine wave, asystole

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35
Q

Pericarditis on ECG

A

ST elevation (saddle shaped) in all leads

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36
Q

ECG territories for MI

ECG leads, heart territory, coronary artery

A

1, aVL, V4, V5, V6 = lateral (circumflex)
V1, V2, V3 = anterioseptal (LAD)
2, 3, aVF = inferior (right coronary artery)

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37
Q

Posterior MI ECG changes

A

Reciprocal changes (upside down changes) are seen. These are changes that appear when looking at ischaemic myocardium from the other side of the heart. Eg. A posterolateral MI would show ‘upside down’ ST elevation in V1-V3.

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38
Q

LBBB on ECG

A

QRS>0.12, W in V1 (due to notching of S wave), M pattern in V6, dominant S in V1, inverted T waves in 1, aVL, V5 and V6

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39
Q

LBBB causes

A

IHD, HTN, cardiomyopathy, idiopathic fibrosis

New LBBB may represent a STEMI

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40
Q

RBBB on ECG

A

QRS>0.12, RSR pattern in V1 (M shape), diminant R wave in V1, inverted T waves in V1, V2, V3. Wide slurred S wave in V6 (W)

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41
Q

Causes of RBBB

A

Normal variant, pulmonary embolism, cor pulmonale

42
Q

Right axis deviation ECG

A

QRS complexes in 1 and 3 +/- 2 are pointing towards each other

43
Q

Causes of right axis deviation

A

RVH, PE, anterolateral MI, WPW, left posterior hemiblock

44
Q

Left axis deviation on ECG

A

QRS complexes in 1 and 3 point away from eachother

45
Q

Causes of left axis deviation

A

left anterior hemiblock, inferior MI, VT, WPW, LVH

46
Q

Systolic vs. diastolic heart failure (how they are different, ejection fractions, causes)

A

Systolic failure - inability of ventricles to contract normally (reduced CO), ejection fraction <40%, causes include IHD, MI, cardiomyopathy

Diastolic failure - inability of ventricles to relax and fill properly, causing icnreased filling pressures, EF >50%, causes include ventricular hypertrophy, constrictive pericarditis, tamponade, restrictive cardiomyopathy, obesity

Systolic and diastolic failure may coexist

47
Q

Left ventricular failure vs right ventricular failure

A

LVF: dyspnoea, poor exercise tolerance, fatigue, orthopnoea, paroxysmal nocturnal dyspnoea, nocturnal cough, pink frothy sputum, wheeze, nocturia, cold peripheries, weight loss, pulm oedema

RVF: peripheral oedema, ascites, nausea, anorexia, facial engorgement, epistaxis
Causes: LVF, pulm stenosis, lung disease (cor pulmonale)

48
Q

Signs of heart failure

A

cyanosis, hypotension, narrow pulse pressure, pulsus alternans, displaced apex (LV dilatation), RV heave (pulm hypertension), signs of valve disease

Peripheral oedema, wheeze, facial engorgement, pink frothy sputum, etc, depending on type of HF

49
Q

Investigations

A

ECG and BNP - if both are normal than alternative diagnosis should be considered. If either is abnormal then echo is required.
BNP raised - ECHO in 6 weeks
BNP significantly raised - ECHO in 2 weeks

Bloods: FBC, U+E, BNP
CXR
ECG (may indicate cause)
Echo (key investigation - may indicate the cause and assess LV function)

50
Q

Severity staging for HF

A

New York Classification of HF
1 = heart disease present but no undue dyspnoea from ordinary activity
2 = comfortable at rest, dyspnoea during ordinary activities
3 = less than ordinary activity causes dyspnoea, which is limiting
4 = dyspnoea present at rest, all activity causes discomfort

51
Q

LVF findings on CXR

A

ABCDE
Alveolar oedema (perihilar bat wing shadowing)
Kerley B lines (sepral lines, due to oedema)
Cardiomegaly
Dilated prominent upper lobe veins
Pleural effusions

52
Q

Acute heart failure management

A

Emergency
Sit patient upright
High flow oxygen
Ix whilst giving treatment (CXR, ECG, U+E, troponin, ABG, ?echo, ?BNP)

Slow IV diamorphine
Furosemide 40-80mg IV slowly
GTN spray. If BP >100 start nitrate infusion (isosorbide dinitrate)

Consider CPAP if patient is worsening

Once stable: daily weight, oral furosemide, ACE-i if EF<40%, consider BB/spironolactone, consider pacing

53
Q

Signs and symptoms of acute heart failure

A

Symptoms: dyspnoea, orthopnoea, pink frothy sputum, any recent drugs?

Signs: distressed, pale, sweaty, tachycardia, tachypnoea, pulsus alternans, raised JVP, fine lung crackles, gallop rhythm, wheeze

54
Q

Bradycardia management

A

Adverse signs -> atropine 500mcg IV ->

  • If unsuccessful repeat atropine up to 6 times, consider transcutaneous pacing, adrenaline, expert help
  • If successful and risk of asystole -> atropine up to 6 times, consider transcutaneous pacing, adrenaline, expert help
  • If successful and no risk of asystole -> observe

No adverse signs -> risk of asystole -> atropine up to 6 times, consider transcutaneous pacing, adrenaline, expert help

No adverse signs -> no risk of asystole -> observe

55
Q

Chronic heart failure management

A

Stop smoking, stop alcohol, less salt, optimise weight and nutrition
Treat cause
Treat exacerbating factors
Annual flu vaccine and one off pneumococcal vaccine

Drugs:
First line: ACE-i (ramipril) and a beta blocker (bisoprolol)
Second line: aldosterone antagonist (spironolactone) or hydralazine in combination with a nitrate
If symptoms persist -> cardiac resynchronisation therapy or digoxin, or ivabradine

Symptom relief: furosemide

56
Q

HTN definitions (clinic and 24hr ambulatory)

A

Clinic readings persistently >= 140/90

24h ambulatory pressure average >= 135/85

57
Q

HTN classification

A

Primary (most common): no single disease causing the rise in BP

Secondary:
renal disease - glomerulonephritis, chronic pyelonephritis, adult polycystic kidney disease, renal artery stenosis
endocrine -
primary hyperaldosteronism, phaeochromocytoma, cushings, liddles, congenital adrenal hyperplasia, acromegaly
others -
glucocorticoids, NSAIDs, pregnancy, coarctation of the aorta, COCP

58
Q

HTN investigations

A

24hr BP monitor
Fundoscopy (hypertensive retinopathy)
Urine dipstick (renal disease)
ECG (LVH, IHD)

U+E - renal disease (cause or consequence)
HbA1c
Lipids

59
Q

HTN Mx

A

Low salt, low caffeine, stop smoking, stop alcohol, fruit and veg, exercise, lose weight

ABPM>=135/85 (stage 1 HTN): treat if <80 and end organ damage/CVD/CKD/DM, consider drugs and lifestyle to adults <60 with stage 1 HTN
ABPM >=150/95 (stage 2 HTN) offer drug Mx regardless of age

<55 or T2DM -> A -> A+C or A+D -> A+C+D

> 55 and no T2DM or afro-caribbean and no T2DM -> C -> A+C or A+D -> A+C+D

60
Q

Blood pressure classification (stage 1, stage 2, severe)

A

Stage 1: clinic BP >=140/90 and ABPM average >=135/85
Stage 2: clinic BP >=160/100 and ABPM >=150/95
Sever: clinic systolic >=180 or clinic diastolic >=110

61
Q

BP targets with treatment

A

<80 - clinic 140/90, ABPM 135/85

> 80 - clinic 150/95, ABPM 145/85

62
Q

What is rheumatic fever

A

Systemic infection. More common in developing countries. Recurs unless prevented.
Pharyngeal infection with group A beta-haemolytic streptoccoci triggers rheumatic fever 2-4 weeks later.

63
Q

Diagnostic criteria for rheumatic fever

A

Jones criteria. Must be evidence of recent strep infection plus 2 major criteria or 1 major and 2 minor.

Major criteria: carditis/endocarditis, arthritis, subcut nodules, erythema marginatum, sydenhams chorea

Minor criteria: fever, raised ESR/CRP, arthralgia, prolonged PR interval, previour rheumatic fever

64
Q

Management of Rheumatic fever

A 
Bed rest until CRP normal for 2wks
Benzylpenicillin IV stat then phenoxymethylpenicillin PO QDS for 10 days
Analgesia (aspirin or NSAIDs)
Immobilise joints in severe arthritis
Haloperidol/diazepam for chorea
65
Q

Causes of mitral regurgitation

A

LV dilatation, annular calcification (elderly), rheumatic fever, infective endocarditis, mitral valve prolapse, connective tissue disorders, cardiomyopathy, congenital

66
Q

Symptoms and signs of mitral regurgitation

A

Symptoms: SOB, fatigue, palpitations, plus symptoms of underlying cause
Signs: AF, displaced hyperdynamic apex, pansystolic murmur at apex radiating to axilla, soft S1 split S2, loud P2. the more severe the larger the left ventricle

67
Q

MR Mx

A

control rate if fast AF
Anticoag if: AF, hx of VTE, prosthetic valve, additional mitral stenosis

Diuretics improve symptoms

Valve replacement or repair

68
Q

Mitral valve prolapse causes

A

Most common valvular abnormality

Occurs alone or with: ASD, turners, PDA, cardiomyopathy, marfans, osteogenesis imperfecta, WPW

69
Q

Signs of mitral valve prolapse

A

Mid systolic click and/or a late systolic murmur

70
Q

Mitral valve prolapse management and complications

A

Management: beta blocker and/or surgery
Complications: MR, cerebral emboli, arrhythmia, sudden death

71
Q

Mitral stenosis causes

A

rheumatic fever, congenital, prosthetic valve

72
Q

Signs and symptoms of mitral stenosis

A

Symptoms of pulm hypertension: dyspnoea, haemoptysis, chronic bronchitis
Hoarseness, dysphagia, bronchial obstruction, fatigue, palpitations, chest pain, emboli, infective endocarditis

Signs: malar flush on cheeks, low vol pulse, AF, RV heave
Loud S1, opening snap, rumbling mid-diastolic murmur

73
Q

Mx of mitral stenosis

A

rate control and anticoag if in AF
Diuretics reduce preload and pulm venous congestion
Balloon valvuloplasty if non-calcified
Open mitral valvotomy or valve replacement

74
Q

Aortic stenosis causes

A

senile calcification, congenital, rheumatic fever

75
Q

Signs and symptoms of aortic stenosis

A

syncope, angina, heart failure (exertional dyspnoea), dizziness, emboli

Slow rising pulse with narrow pulse pressure, heaving apex beat, LV heave, aortic thrill
Ejection systolic murmur heard at the left sternal edge, base and aortic area, radiating to carotids

76
Q

Management of aortic stenosis

A

Valve replacement

Percutaneous valvuloplasty for pt not fit for surgery

77
Q

Aortic regurgitation causes

A

Acute: infective endocarditis, ascending aortic dissection, chest trauma
Chronic: congenital, connective tissue disorders, rheumatic fever, RA, HTN, osteogenesis imperfecta

78
Q

Signs and symptoms of aortic regurgitation

A

Exertional dyspnoea, orthopnoea, PND, palpitations, angina, syncope, HF
Collapsing water hammer pulse, wide pulse pressure, displaced apex beat, high pitched early diastolic murmur (heard best in expiration with patient sat forward), head nodding with each heart peat, carotid pulsation, capillary pulsation in nail bed, pistol shot sound over femoral arteries

79
Q

Management of aortic regurgitation

A

Reduce systolic hypertension (ACE-i)
Echo regularly
Treat underlying cause
Valve replacement

80
Q

Infective endocarditis risk factors

A 
previous episode of IE
Renal failure, DM, immunosuppression, skin breaches
Previously normally valve (mitral valve most common)
Rheumatic valve disease
Prosthetic valve
Congenital heart defects
IVDU
Recent piercing
81
Q

Causative organisms of IE

A

Staph aureus most common cause
Strep viridans most common in developing countries
Staph epidermidis common in post-op (indwelling lines)

82
Q

Signs and symptoms of IE

A

Fever + new murmur = IE until proven otherwise

Septic signs, new murmur (due to vegetations), heart block, vasculitis, microscoping haematuria, AKI, retinal haemorrhages, splinter haemorrhages, osler nodes, janeway lesions, emboli

83
Q

Diagnostic criteria for IE

A

Modified Duke Criteria (2 major, or 1 major and 3 minor, or all 5 minor)

Major: positive blood culture, encocardium involved

Minor: predisposition, fever >38, vascular phenomena, immunological phenomena, positive blood culture that does not meet major criteria

84
Q

Investigations for IE

A

Blood cultures (three sets at different times)
Bloods: FBC, ESR/CRP, U+E, Mg, LFT, RhF +ve
Urinalysis for microscoping haematuria
CXR (cardiomegaly, pulm oedema)
ECGs (heart block)
Echo (vegetations only if >2mm, mitral valve lesions, aortic root abscess)
CT to look for emboli

85
Q

Management of infective endocarditis

A

Initial blind therapy: amoxicillin or gentamicin/vancomycin

Staph IE: flucloxacillin (add rifampicin and gentamicin if prosthetic valve)

Strep IE: benzylpenicillin

Surgery: severe valve incompetence, aortic abscess, abx resistant, cardiac failure, recurrent emboli

86
Q

Dilated cardiomyopathy

  • what is it
  • associations
A

Dilated flabby heart of unknown cause

Associated with alcohol, HTN, chemo, haemochromatosis, viruses, autoimmune, peri/post partum, thyrotoxicosis, congenital

87
Q

Hypertrophic cardiomyopathy (HOCM)

A

LV outflow tract obstruction from asymmetrical septal hypertrophy
Leading cause of sudden cardiac death in the young
Autosomal dominant, or sporadic
Mx: beta blockers, verapamil, amiodarone, anticoag, septal myomectomy

88
Q

Acute pericarditis causes

A 
Idiopathic
Virus (coxsachie)
Bacteria (TB, pneumonia, rheumatic fever)
Autoimmune
Drugs
Metabolic (uraemia, hypothyrdoidism)
trauma/surgery
Malignancy/Radiotherapy
MI/Chronic heart failure
89
Q

Clinical features of pericarditis

A

Central chest pain worse on inspiration or lying flat, relief by sitting forward
Pericardial friction rub may be heard
Pericardial effusion and cardiac tamponade may be seen
Fever may occur

90
Q

Ix for pericarditis

A 
ECG (saddle shaped concave ST elevation in all leads, and PR depression)
Bloods: FBC, U+E, ESR, cardiac enzymes
CXR (cardiomegaly)
Transthoracic echo
CMR or CT
91
Q

Mx of pericarditis

A

NSAIDS or aspirin with gastric protection for 1-2 weeks
Add colchicine for 3 months to reduce recurrence
Bed rest
Treat cause
If autoimmune consider steroids

92
Q

Pericardial effusion causes

A

Pericarditis, myocardial rupture, aortic dissection, pericardium filling with pus, malignancy

93
Q

Clinical features of pericardial effusion

A

Dyspnoea, chest pain, nausea, bronchial breathing, muffled heart sounds, cardiac tamponade?

94
Q

Diagnosis and management of pericardial effusion

A

CXR (enlarged, globular heart)
ECG (low voltage QRS complexes)
Echo (echo-free zone surrounding the heart)

Management: pericardiocentesis may be diagnostic or therapeutic

95
Q

Constrictive pericarditis

  • what is it
  • clinical features
  • tests
  • management
A

rigid pericardium
Presents with RVF -> raised JVP, kussmaul sign (raised JVP with inspiration), soft diffuse apex beat, quiet heart sounds, S3, hepatosplenomagely, ascites, oedema
Tests: CXR (small heart), CT/MRI, echo, cardiac catheterisation
Mx: surgical excision, medical treatment to address cause and symptoms

96
Q

what is a cardiac tamponade

A

Pericardial effusion that raises intrapericardial pressure reducing ventricular filling and thus dropping cardiac output

97
Q

Clinical features of cardiac tamponade

A

tachycardia, hypotension, pulsus paradoxus, raised JVP, kussmaul sign, muffled S1 and S2

98
Q

Diagnosis of cardiac tamponade

A

Becks triad (hypotension, raised JVP, muffled heart sounds)
ECG: low voltage QRS complexes
Echo is diagnostic (echo-free zone)

99
Q

Management of cardiac tamponade

A

Urgent pericardiocentesis (send fluid for cytology, staining and cultures)

100
Q

DVLA rules for

  • angina
  • MI
  • Dysrrhythmias
  • pacemaker implant
  • syncope
  • HTN
A
  • angina: stop if symptoms occur at rest or with emotion. Can continue when under control.
  • MI: stop for 4 weeks if CABG, stop for 1wk if angioplasty
  • Dysrrhythmias: stop for 4wks after successful control
  • pacemaker implant: stop for 1 wk
  • syncope: no restriction if simple faint, stop for 4wks if cause identified and treated, stop for 6 months if cause not identified/treated
  • HTN: can continue unless treatment causes unacceptable side effects

Medicine (15 decks)

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